Jacobs, Raymond NEW YORK STATE DEPARTMENT OF HEALTH 30
Vital Records Section •__,.•,, Burial - Transit Permit
::' Name First Middle Last Sex
Raymond Jacobs Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 1, 2012 90 War or Dates
+i �., Place of Death Hospital, Institution or
:Z' City, Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
tl Michael Adams MD
_. Address
Rt 9. South Glens Falls,NY 12803
D• eath Certificate Filed — District Number Register Number
City, Town or Village Glens Falls 5601 I q
❑Burial Date Cemetery or Crematory
May 3, 2012 Pine View Crematorium
❑Entombment Address
lJ Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
P• ermit Issued to Registration Number
'y:a; Name of Funeral Home Regan & Denny Stafford Funeral Home 01443
• Address
=i 53 Quaker Road,Queensbury,NY 12804
aa, Name of Funeral Firm Making Disposition or to Whom
44, Remains are Shipped, If Other than Above
$ A• ddress
:lam
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 ) 3/ /Z Registrar of Vital Statistics ii. r .J 4 '
(signature)
:, District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 5-ti-j'L Place of Disposition g,.AUt -i Crtfit-r PCI A,
2 (address)
W
(13
Ce
(section) 4 (lot tuber) C (grave number)
p• Name of Sexton or Pe son in Charge f Premises L h it 1 e.miti-
W (ple se print)
Signature III—
Title CaL 61 }wVL
(over)
DOH-1555(02/2004)